On a hot summer day in 1991, in the village of
Licoma, high in the isolated Andean mountains of western
Bolivia, our Save the Children staff members sit through
another tedious meeting. The small, crowded room stinks
like a dirty sauna. Wooden tables, wooden chairs, and the
wooden floor barely absorb the sweat of 24 bodies. No
electricity means no fans, and open windows only invite in
more flies. Eyelids drift downward. Hands cover yawns.

Suddenly, the screen door bangs open. A pre-adolescent boy
stands there panting, his black hair wet with sweat from
running down the mountain. "Come quick," he says, looking
at me. "The baby won't come out, and Papá told me to
bring you." I am the midwife-in-residence working for Save
the Children in this province. I recognize the boy as the
eldest son of Carmen and Juan, a couple who recently made a
prenatal visit.

A staff driver, Alberto, volunteers to take us to the
footpath leading up the hill to Juan and Carmen's village.
We drive down the dusty road as fast as we dare and soon
find the footpath to begin our climb. Forty-five minutes
later we arrive, breathless, knees wobbly, hearts pounding.
I survey the cluster of adobe huts. We hear sobbing from
one small home — the one the boy walks toward. A few
men and women sit on the dirt patio under the shade of a
large fig tree, quietly staring at us.

I enter the dark interior. "What happened?" I ask, panting.
Juan kneels on a dirt floor next to a very still Carmen,
who is prostrate on a red wool rug. Wiping away tears, he
explains, "My wife was in labor all night and this morning.
The baby finally came out. Then she looked at me with
terror in her eyes, and she died! Just like that!" He holds
her hand in one of his and covers his face with the other,
crying.

I search my birth bag for a stethoscope. What could have
happened? Her body is still warm, though I hear no
heartbeat. A small circle of blood coagulates between her
legs. "No hemorrhage," I decide, due to the small amount of
bleeding. Maybe the uterus tore. I feel the womb to
determine rupture, but it feels intact. No twin inside. No
placenta nearby.

Then I remember the baby.

"Where's the baby?" I ask, grabbing Juan's shoulders. He
points to the other side of the room, where, on top of some
dried sheep skins, a naked, fat baby boy lies still. He is
wet, barely breathing, and cold to the touch.

Grabbing a nearby piece of cloth, I pick the baby up and
race outside. Rubbing him warm and dry, I try to stimulate
his heartbeat. Approaching a silent woman sitting nearby
breast-feeding a toddler, I tell this mother what I need to
do, shove the toddler out of the way, and place the newborn
onto her bare skin.

"We have to warm up the baby," I say, "so his heart will
beat and to make him cry. If you stimulate a baby like
this, and he cries, he'll be all right."

Oh, please cry, I silently beg, rubbing him while the woman
stares up at me. Within a minute, the baby cries and begins
suckling. Ah! That miraculous sound!

Relieved, I look for a spot in the shade where I can catch
my breath and collect my thoughts. But no one moves over to
let me under the tree. No one offers a tin cup of water
— the usual custom when an outsider visits a village.
No one congratulates me or smiles with shared relief.

The women stare at their bare feet. Some men look me in the
eyes without any gesture of gratitude or contentment. Am I
the only one who feels a sense of accomplishment? One
dark-brown, weathered farmer finally voices what the others
are apparently thinking.

"Why did you do that, doctora? Who will feed this
baby now? Who will take this baby now that the mother has
died? Will you? You should have left alone what nature had
intended."

When I began to work for Save the Children in 1991,
I had had no previous experience with cultures or
governmental health policies outside of the United States.
I didn't know, for example, that when contraceptives began
to appear in Bolivian towns in the late 1960s, rumors
circulated that the U.S. Peace Corps was attempting
"genocide" of Aymara or Quechua indigenous peoples. In the
1970s and '80s, under Bolivian dictator General Hugo
Banzer, health policy prohibited the distribution of family
planning information, made abortion illegal, and encouraged
couples to have as many children "as God gave them." Those
policies changed in 1990, when Bolivians elected a new
government. The new leaders appointed health ministers more
open to family planning, and World Bank loans to the
country offered incentives to promote family planning.

Radio campaigns were easy enough, but access to pills,
condoms, or IUDs was difficult due to the isolation of the
residents, or to their resistance to imposition from
"outsiders." For many years, family planning methods were
unheard of in rural provinces. Women lived their entire
reproductive lives pregnant, lactating, or post-partum.
During this time, Bolivia had the highest maternal
mortality rate in the Western Hemisphere. (Today it is
second only to Haiti.)

Many rural people counted on traditional methods —
celibacy or waiting three months after childbirth —
for spacing children or reducing the number of pregnancies.
Other traditions included plant medicine to abort a fetus,
and sometimes a vaginal insertion of caustic substances to
provoke abortion, which could be deadly to the mother. When
those methods failed, infanticide was one time-honored
backup method.

"Here is a crying,
wiggling, full-term baby boy," I say. "This is a baby, not
a puppy. I'm not going to put a knife in his heart or
drown him now. Will you? Or you?"

I was therefore surprised and delighted when Carmen, a
32-year-old Aymara Indian eight months pregnant with her
10th baby, walked two hours from her mountain home to the
health post for a prenatal visit. Juan accompanied her. He
had attended Carmen's previous nine births at home without
a hitch. But now they wanted to meet the new gringa
midwife
and get information about avoiding further pregnancies.

Short and slightly built, Carmen was a little pale but
still had most of her teeth, which was a good sign. I
talked with the couple about Carmen's risk of hemorrhage,
her nutrition, and their knowledge about family
planning.

Juan looked a little older than Carmen. He had Brazil-nut
brown skin with thick, calloused farmer's hands. He and
Carmen touched hands quite often, an unusual gesture of
affection between a rural Indian husband and wife.

Despite my urgings, Carmen refused to give birth at the
health post. She preferred her own home, where she had
given birth nine times before.

"Please send someone for me when you start labor," I told
her, then said to Juan, "I'd be happy to assist you and
Carmen — free of charge!" He smiled at me to be
polite. Deep lines surrounded his brown eyes, and I
couldn't help but wonder if he was laughing at the very
idea of me helping him with the birth.

Now, only a few weeks after that calm prenatal
visit, I find myself having to justify to Carmen's angry
neighbors why I am struggling to save her child's life.
I'm
confused and hurt. I consider my fear and my response to
this accusation while wondering about the Spanish word for
"lynch mob." Shaking inside, I take some deep breaths. My
mouth is so dry, how can I speak? I finally stand up and
walk over to the woman still breast-feeding the baby.

"Here is a crying, wiggling, full-term baby boy," I say. I
retrieve the "bundle of joy" from the unhappy woman, and
hold him out at arm's length for all to see.

"This is a baby, not a puppy. I'm not going to put a knife
in his heart or drown him now. Will you? Or you?" I ask,
pushing his squirming, healthy body into the faces of a
few
men around me.

But I know exactly what they're talking about. In Spanish,
as in English, "to kill" and "to allow to die" are
different verbs and different concepts.

"Well," I retort, "he's not an animal, he is a human
being.
He has a father and brothers and sisters and a family and
a
community, and now you want to kill him — because to
let him starve to death is the same as killing. It's
slower
and crueler than a knife, too."

"But how will his father feed him, doctora?"
another
woman says. "How will his brothers and sisters take care
of
him now that they have lost their mother?" These farmers,
hardened by surviving a hand-to-mouth existence, all nod
their heads in agreement. We argue intensely. More people
gather for this impromptu community meeting.

I suggest we ask the opinion of the father, now standing
at
the open door of his home. Grief stricken, Juan waves us
away. I ask the village elders for their opinion. I ask
the
siblings for theirs. (The older boy offers to keep the
baby
with him, which brings guffaws and grunts all around.) I
talk about adoption. Everyone has an opinion, and they all
want to punish me for bringing this dilemma into their
lives.

"YOU take him! You're the one who saved his life!" someone
shouts at me.

"I am very sorry, but I cannot," I reply. "The Bolivian
government prohibits foreigners from adopting Bolivian
babies."

I offer to buy baby formula and bottles for anyone who
takes the child. I ask about other couples in other
villages nearby who might be willing to raise him. Juan
comes out of his hut and sits with us. He says he will
regalar (literally "to gift") his son to anyone who
wants him. There are no takers.

At long last, a tiny, wrinkled grandma hauls herself up
from the dirt using her cane. She says nothing at first,
until everyone becomes quiet and looks toward her. Her
eyebrows come together in anger and her lips press tight
into a straight line. She speaks to the crowd in a shaky
voice, her finger pointing impolitely at each of them.

"I'll take the boy," she declares. "You all know me. I
have
nothing in my home. Nothing. But I have love. And that is
something I see here no one has. That is what makes you
poor."

I stand up to hug her, but she only allows a kiss on the
cheek. While I talk with her about arranging a drop-off of
baby bottles, formula, and cloth diapers, she continues to
glare at the people sitting around the dirt patio. They
examine their feet, do not return her gaze, and then begin
to leave.

Did Carmen have to die? What could have prevented
her death? Why do women continue to give birth at home,
instead of with trained health care providers? What
difference can service organizations, such as Save the
Children, make in the world? I didn't think about those
questions then; I only focused on saving one life, like
all
midwives do in each instant that confronts us. I can only
guess that Carmen may have died of an embolism or perhaps
a
ruptured uterus. An autopsy is prohibited in Aymara
culture, and the custom is to bury the dead within 24
hours.

While all the "negotiating" about the baby's fate was
taking place in the yard, two elderly aunts had been
washing and preparing Carmen's body. They called me in at
one point to ask what they should do about the placenta
still inside her. In Aymara tradition, it's important to
bury the placenta in a secret place near the home so the
spirit won't come back to claim the life of the baby.

"Well, since she is now a spirit herself," I said, "Maybe
we should just bury her with the placenta inside —
what do you think? Then they will both protect the
baby."

They agreed, and that night, Carmen Maria, 32 years old,
mother of 10 children, wife to Juan for 14 years, was laid
to rest under a full moon rising over the steep tropical
mountains of western Bolivia.

Ann Davenport, A&S '05 (MA), is a nurse, midwife, and a
consultant for
JHPIEGO, a Johns Hopkins affiliate that improves
health
care internationally for women and children. This spring,
she received a master's degree from the Writing Seminars.